7tumor abdomen_dr endang
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Abdominal Solid Tumor:Clinical Diagnosis and
ManagementEndangWindiastutiHematology-Oncology DivisionDepartment of Child Health
FMUI dr Cipto M Hospital, J akarta
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Abdominal Mass
Serious finding
Very broad spectrum of pathologies
From small lesions to large ones occupying peritoneal cavity,
from benign to malignant From unilocular cysts to complex solid ones
Need to find out if :
Malignant ? Compressing vital organ ?
There is intestinal hemorrhage ? The older the child the more likely the mass represents
a malignant process
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Objective
Points to address in history taking
Physical findings associated with abdominal
mass Routine laboratory and imaging studies
needed
Overview of most common pediatricabdominal mass
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General Approach
History
Onset
Location
Associated Symptoms
Physical Examination
Inspection
Auscultation Percussion
Other Maneuvers
Special investigation
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History Onset acute
chronicprogression
Location Upper Abdomen
Lower Abdomen
Associated Symptoms
Pain Urinary Symptoms
Fever OBGY Symptoms Abd distension Endocrine/ Cardio
GI Symptoms Hematologic
General Approach
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History Antenatal : Any abnormalities on antenatal
Poly/oligohydramnionUltrasound findings
Duration Age : neonates and infant / older children
Rate of growth Significant family history (adenomatous
polyposis) Inherited predisposition
General Approach
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Clinical History
Age is important
Neonatal Congenital malformations
(GUT / GIT abnormalities)- malignancies uncommon
Older infants and Children(peak age 1-5 years old)
Wilms and Neuroblastoma mostlyGerm cell tumorsNon-Hodgkin lymphoma
Adolescents Non-Hodgkin lymphomaConsider :Inflammation process and pregnancy
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Physical Examination
Inspection : Shape of abdomen Scar Superficial lesions Bulges
Auscultation : bowel sound, bruit
Palpation : tenderness, rigidity, character of mass Percussion : distinguishes causes of distention (gas, fluid, solid)
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Abdominal Examination
Site : - central / flank- pelvic filling- unilateral/bilateral
- crossing midline Characteristics : -size
- consistency- tender
- smooth /nodular- mobile / fixed
Associated findings : ascitespleural effusion
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Initial Blood Work
Renal function/ Possible renal Electrolyte involvement / impairment
Uric acid/ Increased cell turn over LDH (+ALT) suggesting malignancy
FBC / Diff Bone marrow involvement
LFT Liver involvement
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Laboratory Examination
CBC : WBC with left shift (infection)
Pancytopenia :
Bone Marrow infiltration by malignancy
Marrow suppressed by infection
Thrombocytosis
Often seen with liver tumor(thrombopoietin produced by tumor)
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Coagulation studies
Presence of DIC
Liver dysfunction Urinalysis
Hematuria or proteinuria
(Renal and bladder function) Tumor Markers :
Urine VMA, AFP, HCG
Laboratory Examination
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Tumor Specific Investigation
Tumor markers AFP HepatoblastomaHepB sAg Hepatocellular Ca HCG Germ cell tumors
Urine HVAs Neuroblastoma Ferritin Neuroblastoma
Urine NMA (24 hrs) Pheochromocytoma
ESR Lymphoma
Special Investigation : bone marrow puncture / biopsy Neuroblastoma Malignant rhabdoid tumor
Lymphoma Renal clear cell sarcoma
Rhabdomyosarcoma
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Initial Imaging for Diagnosis
X-Ray Abd XR :Controversial as to necessityDescribe location & density?Obstruction
?Calcification
Chest XR :MetastasisStaging
Malignant effusionExclude TB
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Ultrasound
Cheap and readily available
Sedation not necessary Good initial imaging helpful with initial
diagnosis
Organ of Origin
Tissue components : cysts, hemorrhage,calcification
Vascular lesions (doppler)
Initial Imaging for Diagnosis
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Further Imaging
CT-Scan : if suspicious of malignancy
Determination size and infiltration into vessel or vital organ
MIBG Scan Neuroblastoma
Bone Scan Neuroblastoma
Clear cell sarcoma
PET Scan Lymphoma
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Further Imaging
MRI
Best imaging ofabdominal tumors(abdomen & pelvis)
Expensive
No radiation :
implications forinitial and follow upscans.
CT Chest
Essential to assesschest metastases
CT Abdomen
Good imaging forblood vessels
Radiation : Implicationfor follow up imaging
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Abdominal Mass
History and PE
Abdominal WallIntra -Abdominal
Infectious Non-Infectious
Malignant Non-Malignant
Intraperi toneal Retroperitoneal
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Neonatal Abdominal Masses
Renal 55% Hydronephrosis 35% Cystic disease 10%
Multicystic dysplastic Polycystic dysplastic
Solid Tumors 10% Mesonephric nephroma nephroblastomatosis
Pelvic / Genital 15% Teratoma Ovarian Cysts Hydrometrocolpos Obstructed bladder
Non-Renal Retroperitoneal 10% Adrenal
Hemorrhage
neuroblastoma
Gastrointestinal 15% Duplication Mesenteric omental cyst Pseudocyst from
complicated obstruction
Meconiumileus Hepatobiliary 5%
Hepatic tumors Hemangioendothelioma Cystic mesenchymal
hamartoma
Hepatoblastoma Neuroblastoma
Choledochal cyst
Kirk et al., 1981 Radiol. Clin. North Am., 19:527-545
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Distribution of abdominal mass in neonates by organ systemKirks et al. Radiol Clin North Am 1981;19:527-545
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Abdominal Masses in Older Children
Renal 55%
Wilms (& other) 25%
Hydronephrosis 20%
Cystic disease 5%
Non Renal Retroperitoneal 23%
Neuroblastoma 21%
Teratoma 1%
Other 1%
Gastrointestinal 12%
Appendiceal Abscess
Lymphoma
Hepatobiliary 6%
Tumors
Hepatoblastoma
HCC
Genital 4%
Ovarian Cysts andTeratoma
Kirk et al., 1981 Radiol. Clin. North Am., 19:527-545
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The Commonest Malignant
Abdominal Masses in Children:1. Neuroblastoma.
2. Wilms tumor (Nephroblastoma).
3. Malignant lymphoma (usually Non-Hodgkinlymphoma of the intestine).
4. Hepatoblastoma.
5. Lymphosarcoma.6. Other Suprarenal tumors (Non Neuroblastoma).
7. Others .
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The commonest benign masses
1. Hydronephrotic kidney (Peliviuretericjunction obstruction), polycystic kidney.
2. Mesenteric mass and cysts.
3. Intestinal Duplication cysts.
4. Hydatid cysts in the older children
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A mass in the toddlers (1-3 years).
Triad of :1. Abdominal Neuroblastoma
2. Wilms Tumor.
3. Hydronephrosis.
Minimal local or general symptoms, usually themass discovered by the mother.
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Region Organ Diagnosis
Epigastrium Stomach Distended stomach from pyloric stenosis, duplication
Pancreas Pseudocyst
Flank Kidney hydronephrosis, Wilms tumor, dysplastic kidney, ureteral duplication
Adrenal Neuroblastoma, ganglioneuroblastoma, ganlioneuroma
Retroperitoneal Neuroblastoma, ganglioneuroblastoma, ganglioneuroma, teratoma
Lower abdomen Ovary Desmoid, teratoma, ovarian tumors, torsion of ovary
Kidney Pelvic kidney
Urachus Urachal cyst
Omentun,mesentery Omental, mesenteric, peritoneal cysts
Pelvic Bladder, prostate Obstructed bladder, rhabdomyosarcoma
Uterus, vagina Hydrometrocolpos, hydrocolpos,rhabdomyosarcoma
Right upper quadrant Biliary tract Cholecystitis, choledochal cyst
Liver Hepatomegaly (congestion, hepatitis), hamartoma, hemangio-endothelioma, hepatoblastoma, hepatocelullar Ca, abscess,cyst
Intestine intussusceptions, duplicationLeft upper quadrant Spleen Splenomegaly (infection, leukemic infiltration, abscess, cyst)
Right lower quadrant Appendix Appendiceal abscess
Ileum Meconium ileus, inflammatory mass
Lymphatic Lymphoma, lymphangioma
Left lower quadrant Colon Fecal impaction
Lymphatic Lymphoma, lymphangioma
Atlas of Pediatric Physical Diagnosis, Fourth edition
Possible Diagnoses of Abdominal Masses in Infancy and Childhood
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Work up two components
Staging X-ray of primary site
CT chest, abdomen, &pelvis
CXR (baseline) Bone scan
Specialty tests
Gallium, MIBG, PET
Bone marrow
ESR
Evaluate for complications ofthe tumor
CBC with diff. count
Others
LDH, uric acid tumor lysis, rapidcell growth
Creatinine renal function
Transaminases hepaticinvolvement
Specialty tests
Tumor markers
HCG, AFP
HVA / VMA
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Tissue Diagnosis
Incisional biopsy
Excisional biopsy
Special cases
Calicified suprarenal mass + bone scan might consider getting dx from bone marrow
FNA vs excisional biopsy
Bias towards excisional sufficient sampleto be representative and to send for specialresearch studies (histology, chromosomes,special studies, research studies)
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Algorithm for Evaluation of a Neonatal Mass
Abdominal Mass
Abdominal Radiograph
Bowel gas displacement
Surgery
Bowel obstruction
Consider :Contrast studies
Calcifications
Consider :NeuroblastomaTeratomaHepatoblastomaMeconiumperitonitis
ULTRASOUND
Flank Mass
Confirmed
Intraperitoneal Mass Pelvic Mass
Adrenal Origin Renal Other
Solid Cystic
Solid Cystic Complex CysticSolid
Schwatz Mz, Shaul DB. Ped in Rev 1989;11:172-9
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Algorithm for Evaluation of a Neonatal Mass
Flank Mass
Adrenal Origin Renal Other
Solid Solid SolidCystic Cystic Cystic
CT-scan CT-scan CT-scan
Neuroblastom
Adrenalhemorrhage?
Surgery
Observation
Mesoblastik
Nephroma
Wilms Tumor
NormalUreter
DilatedUreter
Surgery
IVP,Renal
Scan
Multicystic
kidney
Obstruction
Surgery
No reflux
RefluxObstructionNeurogenicBladder
Surgery
Surgery
Neurogenic
Bladder
Teratoma,
Sarcoma
Neurobl
Lymphangioma
Surgery
Schwatz Mz, Shaul DB. Ped in Rev 1989;11:172-9
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Algorithm for Evaluation of a Neonatal Mass
Intraperitoneal Mass
Solid Cystic Complex
CT
Organomegaly
Tumor :
Hepatoblastoma
Hemangioma
Surgery
Angiogram ?
Ovarianmesentric
omental
Intestinal
duplication
Spleen
Surgery
Ovarian
teratomaMeconium cyst
Surgery
Schwatz Mz, Shaul DB. Ped in Rev 1989;11:172-9
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Conclusion
Abdominal masses in neonates and children reflect awide spectrum of diseases
The patients age is among the most important factors
that help narrow the potential etiologies of an abdominalmass
Plain abdominal radiographs should be the first imagingstudies to evaluate an abdominal mass
It is important for physician to determine the nature ofthe mass in a timely, safe, and cost-effective manner.
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